Millions of rural Texans as well as many inner-city residents have difficulty getting health care—medical, dental, as well as mental and behavioral—when they need it. There is a shortage of providers, both an insufficient number of doctors as well as mal- distribution.

Midlevel providers could ameliorate the problem, but a reg- ulatory barrier called a Prescriptive Authority Agreement (PAA) restricts their ability to care for patients.

In Texas, Advanced Practice Registered Nurses (APRNs) cannot treat patients without a PAA, an expensive contract with a physician who delegates his authority to write prescriptions. In major metropolitan hospitals, the institution pays the cost of the PAA for their APRNs, which averages $20,000 per contract with some priced over $100,000. These prices make it impossible for APRNs to practice independently, particularly in underserved areas, without a hospital paying the cost of the PAA.